Disclaimer and health screening form
Street Address Line 2
State / Province
Postal / Zip Code
Have you ever had any of the following health conditions
Asthma or Breathing problems
Low Blood Pressure
High Blood Pressure
Dizziness/ fainting or vertigo
Are the health conditions past or active medical history
How would you rate your current health status?
Do you have any current injuries?
If Yes please specify
Have you ever suffered from any of the following injuries?
Neck or spinal injury
Lower back injury
Joint injury (hip, ankle, knee, shoulder, elbow)
Please detail your injury below ...
Please be aware if practicing yoga with any injury that you stop if you are in any pain. Yoga should not be painful or cause strain or stress to the body.
Yoga for you
Do you practice yoga for any of the following reasons
Mindfulness (being in the here and now)
Spiritual reasons / connection / enlightenment
Flexibility and strength
Managing a particular condition (please specify below)
Are you pregnant?
Are you active on a daily basis?
Do you engage in any of the following exercise?
High intensity interval training/ boot camp
Disclaimer: If at any time during the practice you experience discomfort or strain, gently come out of the posture. You may rest at any time during the class. It is important in yoga that you listen to your body and respect its limites on any given day. Please read the statement below and sign if you are happy to continue I, the undersigned, understand that yoga is not a substitute for medical attention, examination, diagnosis or treatment. I should consult a GP prior to begining in any activity or yoga programme.I recognise that it is my responsibility to notify my teacher of any serious illness or injury before the yoga class. I will not perform any postures to the extent of strain or pain. I will practice at my own ability at all times. I understand that as with any physcial activity there is a risk to physical injury. I acknowlege I have been asked to consult with my GP before beginning yoga and therefore accept full responsibility to any possibility of injury from the class. I accept that neither the instructor, nor the hosting facility is liable for any injury or damages to person or property resulting from taking the class. Signature (for the disclaimer)
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform